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Diverticular disease


Signs and Symptoms
What Causes It?
Who's Most At Risk?
What to Expect at Your Provider's Office
 
Treatment Options
Following Up
Prognosis/Possible Complications
Supporting Research

Diverticular disease occurs when pouches (diverticula) in the intestine, usually the large intestine or colon, become inflamed. Most diverticula occur in the sigmoid colon, the curved part of the large intestine closest to the rectum, and they tend to become more numerous as we age.

Diverticulosis is the presence of many diverticula along the intestinal wall. It occurs more commonly in countries such as the U.S. where the diet is generally low in fiber. More than 50% of adults over age 70 have diverticula, and 80% have no symptoms.

Diverticulitis occurs when one or more diverticula become inflamed. The inflammation may be local (just in the area of the diverticulum), or may spread to the abdominal lining (peritoneum), called peritonitis. Small (microscopic) or large perforations (holes in the intestinal wall) occur in 15 - 20% of people who have diverticula.

Signs and Symptoms

Often diverticula cause no symptoms, although you may experience irregularities in bowel habits. If symptoms do appear, they may include the following:

  • Abdominal pain, especially after a meal on the lower left side of the abdomen
  • Either painless rectal bleeding or passing of blood in stool
  • Fever
  • Nausea
  • Vomiting
  • Irregular bowel movements, including constipation or diarrhea
  • Gas
  • Bloating

Some people with diverticulitis develop fistulas, or abnormal passageways from the intestines into the abdomen or to another organ such as the bladder. This may lead to a urinary tract infection, gas in the urine, pain while urinating, or a more frequent need to urinate.

Some people develop peritonitis, an inflammation of the lining of the abdomen. Symptoms of peritonitis may include sudden abdominal pain, muscle spasms, guarding (involuntary contraction of muscles to protect the affected area), and possibly sepsis, the term for an infection that has spread to the blood. Peritonitis can be life threatening if left untreated.

What Causes It?

The cause of diverticular disease is unknown, but several factors may contribute to changes in the wall of the colon. These include aging, the movement of waste through the colon, changes in intestinal pressure, a low fiber diet, and physical abnormalities.

Who's Most At Risk?

These factors increase the risk for developing diverticular disease:

  • Low fiber diet
  • Advanced age (more than half of people over age 70 have the condition)
  • Obesity
  • Male gender, for diverticulitis

The following may contribute as well:

  • High fat intake
  • Lack of regular physical activity

What to Expect at Your Provider's Office

Your health care provider will examine your abdomen for tenderness, swelling, and guarding and may try to detect any unusual mass around the intestines. Your health care provider may also test your blood, urine, and stool for signs of infection or blood. A computed tomography (CT) scan, ultrasound, and other imaging techniques may help locate diverticula and any inflammation, fistulae, abscesses, or other abnormalities.

Treatment Options

Prevention

To help prevent diverticular disease:

  • Eat a high-fiber (25 - 35 g per day), low-fat diet that contains lots of vegetables. Such a diet is also beneficial for overall health, and may reduce the risk of heart disease and cancer.
  • Avoid red meat.
  • Avoid foods that may block the opening of a diverticulum and lead to inflammation, such as seeds.
  • Exercise regularly. One study found that men and women who run have a lower risk of diverticular disease than those who don't run.

Treatment Plan

For mild symptoms, your health care provider may recommend a clear liquid diet and prescribe antibiotics. More serious cases may require hospitalization, intravenous (IV) feeding to rest the intestine, IV antibiotics, and IV antispasmodics, which relax the intestine. Eating a high-fiber diet and taking psyllium supplements may help following an attack.

Drug Therapies

Your doctor may prescribe antibiotics to fight infection, antispasmodics to relieve cramping, and analgesics to relieve pain.

Surgical and Other Procedures

If you have repeated episodes of diverticulitis, respond poorly to medical therapy, or have other complications, your health care provider may recommend removing part of the colon. If you have severe complications, or if your condition worsens within 1 - 2 days of attack, you may need surgery right away.

Complementary and Alternative Therapies

Nutrition plays an important role in preventing and treating gastrointestinal disease, especially diverticulosis. You may help minimize attacks and improve treatment results by following specific dietary recommendations.

Nutrition and Supplements

Eat a diet that is high in fiber (25 - 35 g per day). One study suggested that the following foods were associated with a lower risk of diverticular disease: cucumber, lettuce, spinach, and whole-grain bread. Food is the best source of fiber, but you may also use fiber supplements to increase the amount of fiber you take in every day. Common kinds of fiber supplements include insoluble fiber supplements such as psyllium and glucomannan (3 - 5 g per day of either supplement). Your doctor may also suggest soluble fiber supplements, such as flax seed and oat bran, which can be less irritating than insoluble supplements. Talk to your doctor to find the right combination for you.

Glutamine (400 mg 4 times per day, between meals) is an amino acid found in the body that helps the intestine function properly. While there is no evidence that glutamine helps reduce symptoms of diverticular disease, it may be beneficial for overall intestinal health. Do not take glutamine if you are diabetic or have seizures, liver disease, or a history of mania or manic episodes.

Omega-3 fatty acids, such as those found in fish oil, may help fight inflammation. (On the other hand, some omega-6 fatty acids, found in meats and dairy products, tend to increase inflammation.) If you have diverticulitis, eat a diet rich in omega-3 fatty acids, or take a supplement (1,000 mg 1 - 2 times per day). This type of diet may also help prevent colon cancer. Do not take high doses of a fish oil supplement if you are on blood thinning medication. Omega-3 acids have a blood thinning effect and can increase the effect of blood thinning medications, such as Coumadin (warfarin) and aspirin.

Probiotics, such as Lactobacillus acidophilus, Lactobacillus plantarum, Saccharomyces boulardii (250 mg, taken daily between meals) and bifidobacteria, help maintain the health of the intestines. In one study, people who had diverticulitis were more likely to remain symptom-free after 1 year when they were treated with Lactobacillus casei and mesalazine.

Herbs

Herbs are generally a safe way to strengthen and tone the body's systems. As with any therapy, you should work with your health care provider to diagnose your problem before starting any treatment. You may use herbs as dried extracts (capsules, powders, teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, make teas with 1 tsp. herb per cup of hot water. Steep covered 5 - 10 minutes for leaf or flowers, and 10 - 20 minutes for roots. Drink 2 - 4 cups per day. You may use tinctures alone or in combination as noted.

The following herbs are often used to treat gastrointestinal illness:

  • Flaxseed (Linum usitatissimum) may be helpful in treating diverticulosis. It contains fiber and works as a bulk forming laxative, softening stool and speeding transit time through the intestine. Use ground flaxseed, 15 g per day.
  • Slippery elm (Ulmus fulva) is a demulcent (protects irritated tissues and promotes healing). Take 60 - 320 mg per day. Or mix 1 tsp. powder with water and drink 3 - 4 times a day.
  • Cat's claw (Uncaria tomentosa, 250 mg per day) is an anti-inflammatory. Do not take Cat's claw if you are pregnant, have an autoimmune disease, or Leukemia. Cat's claw can interfere with a variety of medications; speak with your doctor.
  • Wild yam (Dioscorea villosa, 2 - 4 g per day in 2 - 3 divided doses). Talk to your doctor before taking wild yam if you have or are at risk of having breast cancer, prostate cancer, or any hormonally influenced condition. There is some concern that Wild yam may increase clot formation in people with Protein S deficiency, a disorder that predisposes people to form clots.
  • Marshmallow (Althaea officinalis) is a demulcent and emollient. Drink 1 cup of tea 3 times per day. To make tea, steep 2 - 5 g of dried leaf or 5 g dried root in 1 cup boiling water, strain, and cool. Avoid marshmallow if you have diabetes. Marshmallow can interfere with the absorption of many medications and can interact negatively with lithium.
  • Chamomile (Matricaria recutita), 1 - 3 cups of tea per day. To make tea, steep 3 g flower heads in 1 cup boiling water, strain, and cool. Chamomile can have some estrogen-like effects, so do not use it if you are pregnant, taking birth control pills, or have a history of hormone-related cancers. High doses may interact with blood thinning medications. Do not use chamomile if you are allergic to Ragweed or related plants.
  • Licorice (Glycyrrhiza glabra, 380 - 1,140 g per day) can reduce spasms and inflammation in the gastrointestinal tract. Do not take licorice for a long period of time, or if you have high blood pressure, heart failure, kidney disease, or hypokalemia. Look for products that contain only DGL, which means the majority of the blood pressure raising component of licorice has been removed.

Homeopathy

While few studies have examined the effectiveness of specific homeopathic remedies, professional homeopaths may recommend one or more of the following treatments for diverticular disease based on their knowledge and clinical experience. Before prescribing a remedy, homeopaths take into account a person's constitutional type -- your physical, emotional, and intellectual makeup. An experienced homeopath assesses all of these factors when determining the most appropriate remedy for a person.

  • Belladonna -- used for abdominal pain and cramping that comes on suddenly and feels better with firm pressure. It is particularly helpful if constipation accompanies the pain.
  • Bryonia -- used for abdominal pain that worsens with movement and is relieved by heat. It is particularly useful if vomiting or constipation with dry, hard stools accompanies the pain.
  • Colocynthis -- used for sharp, cramping abdominal pains that improve with pressure. It is particularly useful if pain is accompanied by restlessness and diarrhea.

Acupuncture

Acupuncture may help relieve pain and other symptoms. Acupuncturists treat people with diverticular disease based on an individualized assessment of the excesses and deficiencies of qi (or energy) located in various meridians. Acupuncture and Chinese medicine in general may promote gastrointestinal health.

Following Up

If you develop a fever, tenderness in the abdomen, or bleeding from the rectum or in the stool, tell your health care provider right away. You may be hospitalized for a fever higher than 101°F, worsening symptoms, signs of peritonitis, or increased white blood cell count found in laboratory tests.

Prognosis/Possible Complications

Most patients with diverticulitis respond well to antibiotics and bowel rest. About one third of people who develop diverticulitis have a second episode, and of this group, half generally have a third attack. About 20% of patients develop complications after the first attack, 60% after a second attack. Complications may include:

  • An abscess (pocket of pus)
  • Blocked intestine
  • A perforation (hole) in the intestine leading to peritonitis, sepsis, and even shock
  • Fistulas, which may also lead to sepsis
  • Bleeding

If you have experienced bleeding once, you are at high risk for bleeding again.

Supporting Research

Aldoori WH, Giovannucci EL, Rimm EB, Wing AL, Trichopoulos DV, Willett WC. A prospective study of alcohol, smoking, caffeine, and the risk of symptomatic diverticular disease in men. Ann Epidemiol. 1995;5(3):221-228.

Aldoori W, Ryan-Harshman M. Preventing diverticular disease. Review of recent evidence on high-fibre diets. Can Fam Physician. 2002 Oct;48:1632-7.

Ambrosetti P, Robert JH, Witzig JA, et al. Acute left colonic diverticulitis: a prospective analysis of 226 consecutive cases. Surgery. 1994;115(5):546-550.

Comparato G, Fanigliulo, Cavallaro LG, et al. Prevention of complications and symptomatic recurrences in diverticular disease with mesalazine: a 12-month follow-up. Dig Dis Sci. 2007;52(11):2934-41.

Ferri F. Diverticular Disease. Ferri's Clinical Advisor 2011, 1st. ed. St Louis, Mo: Mosby; 2010.

Ferzoco LB, Raptopoulos V, Silen W. Acute diverticulitis. N Engl J Med. 1998;338(21):1521-1526.

Floch M, White J. Management of diverticular disease is changing. World J Gastroenterol. 2006;12(20):3225-8.

Fox J, Stollman N. Feldman: Sleisenger & Fordtran's Gastrointestinal and Liver Disease. 8th ed. Philadelphia, Pa: W.B. Saunders; 2006:2613-2617.

Hinchey EJ, Schaal PG, Richards GK. Treatment of perforated diverticular disease of the colon. Adv Surg. 1978;12:85-109.

Ibele A, Heise CP. Diverticular disease: update. Curr Treat Options Gastroenterol. 2007;10(3):248-56.

Kohler L, Sauerland S, Neugebauer E. Diagnosis and treatment of diverticular disease: results of a consensus development conference. Surg Endosc. 1999;13(4):430-436.

Manousos O, Day NE, Tzonou A, et al. Diet and other factors in the aetiology of diverticulosis: an epidemiological study in Greece. Gut. 1985;26(6):544-549.

Nair P, Mayberry JF. Vegetarianism, dietary fibre and gastro-intestinal disease. Dig Dis. 1994;12(3):177-185.

O'Keefe SJ. Nutrition and gastrointestinal disease. Scand J Gastroenterol Suppl. 1996;220:52-59.

Ooi K, Wong Sw. Management of symptomatic colonic diverticular disease. Med J Aust. 2009;190(1):37-40.

Rosemar A, Angeras U, Rosengren A. Body mass index and diverticular disease: a 28-year follow-up study in men. Dis Colon Rectum. 2008;15(4):450-5.

Salzman H, Lillie D. Diverticular Disease: Diagnosis and Treatment. American Family Physician. 2005;72(7):1229-1234.

Sorser SA, Hazan TB, Piper M, Maas LC. Obesity and complicated diverticular disease: is there an association. South Med J. 2009;102(4):350-3.

Strate LL, Liu YL, Aldoori WH, Syngal S, Giovannucci EL. Obesity increases the risks of diverticulitis and diverticular bleeding. Gastroenterology. 2009;136(1):115-122.e1.

Williams PT. Incident diverticular disease is inversely related to vigorous physical activity. Med Sci Sports Exerc. 2009;41(5):1042-7.


Review Date: 10/12/2010
Reviewed By: Steven D. Ehrlich, NMD, Solutions Acupuncture, a private practice specializing in complementary and alternative medicine, Phoenix, AZ. Review provided by VeriMed Healthcare Network.
The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. A licensed medical professional should be consulted for diagnosis and treatment of any and all medical conditions. Call 911 for all medical emergencies. Links to other sites are provided for information only -- they do not constitute endorsements of those other sites. © 1997- A.D.A.M., Inc. Any duplication or distribution of the information contained herein is strictly prohibited.
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